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A Q&A with Kelly Mandagere, MD: Hypothyroidism

Hypothyroidism:  Symptoms, causes and treatments

Q&A with Dr. Kelly Mandagere, Endocrinologist

Hypothyroidism and other thyroid problems
Hypothroidism can cause fatigue, slowed metabolism, difficulties concentrating, and depression.

As an endocrinologist, Dr. Kelly Mandagere is involved in studying, diagnosing and treating conditions of the endocrine system. This network of glands and hormones has widespread effects on the body that include regulating growth, metabolism, reproduction, and sexual development.

Combining her credentials as an endocrinologist with a lifelong passion for the science of medicine, a special interest in biochemistry, and training as a nutritionist, Dr. Mandagere provides a unique understanding of endocrine conditions, including hypothyroidism. In this Boulder Medical Center Q&A session, Dr. Mandagere answers questions about her approach to understanding the causes of, and managing this complex and often challenging disorder.

What is hypothyroidism?

Dr. Mandagere:  The thyroid gland is vital to our metabolism, growth and maturation. Located at the front part of the neck and shaped like a butterfly, our thyroid helps regulate many body functions by releasing hormones into the bloodstream.

If too little thyroid hormone is produced, our body can slow down. This condition is called hypothyroidism.

Hypothyroid (underactive thyroid):  What are the symptoms?

Dr. Mandagere:  Hypothyroidism can affect males and females. Symptoms can include:

  • Loss of energy
  • Slowed metabolism
  • Mild weight gain and difficulty losing weight
  • Fatigue
  • Difficulties concentrating or mental slowness
  • Sensitivity to cold
  • Dry skin
  • Brittle, dry hair
  • Hair loss
  • Depression
  • Erectile dysfunction in men

When do people typically see a thyroid specialist?

Dr. Mandagere:  Many of my patients come to see me for the first time because their primary doctor has diagnosed them with hypothyroidism. Because I specialize in the endocrine system, primary care physicians often refer their patients to me for further consultation and care.

I also see patients who are already being treated for hypothyroidism and their dose of medication changes or is fluctuating. Although these patients are still being treated by a primary doctor, they come to me for a second opinion or when their physician requests help to regulate medication or address persistent symptoms.

I enjoy partnering with many local physicians to ensure that our shared patients get the best care possible.

Some patients also come to me looking for a cure. Unfortunately, there is no cure for hypothyroidism at this point, but I talk with them about treatments that can restore adequate thyroid levels and reduce their symptoms.

What causes hypothyroidism?

Dr. Mandagere:  We talk about the root causes of hypothyroidism. Hypothyroidism is usually from a condition known as Hashimoto’s Thyroiditis. Rather than protect thyroid tissue, the body’s immune system actually attacks the gland, causing inflammation. As the immune system attacks the inflamed thyroid, the tissue is gradually affected and damaged by a process that causes scarring, fibrosis, and eventual loss of thyroid function.

What causes the immune system to attack the thyroid gland?

Dr. Mandagere:  That’s really the million dollar question that we don’t completely understand. We do know how the process works, though.

All of the organs in our body have little markers — let’s call them “red flags” — that tell our immune system that they belong to, and are part of our body. When the immune system doesn’t see or sense these red flags it produces antibodies that attack the gland. Over time, this impairs its ability to produce thyroid hormone, which causes hypothyroidism.

What are treatments for hypothyroidism?

Dr. Mandagere:  As I mentioned before, hypothyroidism cannot be cured. We can, however, prescribe medication that restores adequate hormone levels and reverses the symptoms. Standard treatment involves the daily use of the synthetic hormone, levothyroxine (i.e Levothroid, Synthroid and others). After a simple blood test that measures thyroid function, we determine the appropriate dose of medication.

It’s important to note that, because thyroid function will fluctuate and diminish over time, we need to monitor a patient’s medication throughout their lifetime. Dosage levels are increased or decreased depending on symptoms and results of blood tests. Medication will compensate for the weakened thyroid, eventually taking over when the thyroid ceases to function altogether. The process of destroying the thyroid gland is a slow one, which is why many people who have Hashimoto’s Thyroiditis can go years without symptoms.

For some, increasing their medication to compensate for reduced thyroid function happens over many years. Others go from no medicine to a full dose within six months. I reassure my patients that we will work together to find a dose of medication that will hold things steady at some point.

Additional hypothyroid treatments?

Dr. Mandagere:  Some of my patients ask if mineral, vitamins or herbal supplements can be helpful. As an endocrinologist, I answer these questions based on my knowledge and experience with evidence-based studies and data. With that said, we really don’t have much literature about this area of treatment, except for studies indicating that selenium may help preserve thyroid function.

We also know that healthy living benefits our immune system, which in turn can lead to better thyroid function. I talk with my patients about general recommendations that include good quality sleep, regular exercise, and a lean and green diet that avoids process foods.

What do I need to know about taking thyroid medications?

Dr. Mandagere:  For my patients who are already being treated for hypothyroidism, I emphasize the importance of taking their medication in a consistent manner. If a patient I’m treating comes to me with elevated symptoms, we sometimes find that it doesn’t necessarily mean that their thyroid is slowing down.

This is where, with my passion for, and background in biochemistry and nutrition, things really get interesting in terms of problem-solving with my patients.

We may find that their body is not absorbing the thyroid medication efficiently or that the metabolism of the medication has changed for one reason or another. We talk about a proper dosing routine that includes taking their medication the same time every day on an empty stomach. It’s also important that their thyroid medication is separated by at least four hours from certain vitamins and minerals including calcium, iron and fiber and some cholesterol medications. We also discuss other prescriptions or supplements that might be impacting their thyroid medication.

Simply altering a few a few factors can often improve a patient’s symptoms. For instance, switching to Synthroid, the brand drug from the generic levothyroxine or levothroid has helped some patients. This is because every time you purchase Synthroid at the pharmacy you get the exact same product. You know that the absorption and metabolism is very predictable. When you purchase the generic brand, however, the pharmacy may give you one generic batch one time and a different batch the next. The active drug is the same but the formulation – perhaps the coating on the pill – may be different and can affect absorption.

I prefer prescribing Synthroid for my patients but, of course, the brand is more expensive so a lot people do opt for the generic and sometimes that means more monitoring and adjusting. It’s also true that sometimes people just feel better on one medication than another, and it could have to do with various chemicals in the formulation, so it’s hard to say what will work best for every patient.


About Dr. Kelly Mandagere
Boulder Medical Center

Dr. Kelly Mandagere joined Boulder Medical Center in 2017 after practicing for over 10 years as an endocrinologist in Louisville, Colo. She was board-certified in endocrinology, diabetes and metabolism in 1998 and prior to becoming a physician, Dr. Mandagere earned a Master of Science in Nutrition. In the years leading up to medical school she worked as a registered dietitian, counseling patients and educating physicians and health professionals.


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